Impact of end-stage renal disease on stroke risk in patients with atrial fibrillation.

BACKGROUND: Patients with end-stage renal disease (ESRD) and atrial fibrillation (AF) face paradoxical risks of both thrombosis and bleeding, creating uncertainty regarding stroke risk and optimal anticoagulation (AC) strategies. OBJECTIVES: This study evaluated the impact of ESRD on stroke risk and mortality in patients with AF using a large national cohort. METHODS: A retrospective cohort study was conducted using the National Inpatient Sample database for 2018-2019. Adult patients (≥18 years) with AF were stratified by ESRD status. Propensity score matching (1:1) was performed using baseline demographic and comorbidity variables. Primary outcomes included ischemic stroke, hemorrhagic stroke, transient ischemic attack (TIA), and all-cause mortality. RESULTS: Of 1,749,172 patients with AF, 89,741 (5.1%) had ESRD. After propensity matching (68,653 pairs), patients with ESRD showed significantly lower rates of ischemic stroke (1.8% vs 3.1%; P < .001), hemorrhagic stroke (0.3% vs 0.8%; P < .001), and TIA (0.5% vs 0.6%; P < .001) than patients without ESRD. Patients with ESRD had lower odds of ischemic stroke (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.55-0.63), hemorrhagic stroke (OR, 0.37; 95% CI, 0.31-0.43), and TIA (OR, 0.76; 95% CI, 0.65-0.88) (all P < .001). These findings persisted despite lower rates of oral AC use among patients with ESRD (24.7% vs 29.5%; P < .001). All-cause mortality was substantially higher in patients with ESRD (8.6% vs 4.6%; P < .001; OR, 1.95; 95% CI, 1.87-2.04). CONCLUSION: Patients with AF with ESRD had lower cerebrovascular event rates despite lower AC use, suggesting that uremic platelet dysfunction and intradialytic heparin exposure may confer protective AC effects. These findings challenge traditional stroke risk assumptions and highlight the need for ESRD-specific risk-stratification tools and individualized shared decision making.